Denied ACA Subsidy

Swampy

Dryer sheet wannabe
Joined
Jan 8, 2020
Messages
10
Location
Upton
Hi All,

I left my FT employment job in mid-2020 but continued doing on-call consulting work for them as well as my own consulting work. I continued health insurance via COBRA for my DW and myself which recently ended in Nov. 2021. I applied for health insurance via my state's (MA) health connector website and selected an HSA eligible bronze plan for December 2021 and for 2022. I paid full price (around $1250) for December but was hoping to get subsidized premiums going forward in 2022.

Based on the income information I entered for myself and wife on the state's health connector website, I was told that we qualify for $1,115 month subsidy and would be responsible for the remaining $275/month which sounded fine. I uploaded various documents (primarily 2020 tax forms for self-employment income and interest/dividends and recent paystubs for our 2021 income) to verify our income on the website but then received a letter via mail that we don't qualify for any subsidy because our income is too high.

My 2021 income is $57K from my former employer of which approximately $25K is put into the 401k I have with my former company (supported by including my most recent paystub). I also receive approximately 14K profit/year from self-employment income while my DW makes about $24.5K from her part-time work. We also receive about 2K a year in interest/dividends. After including deductions for HSA, SEP and LTC insurance our AGI is 53.5K a year which would provide the subsidy of $1,115/month as we are at 320% of the FPL. Does the fact that I am putting that much $ into my 401k from my income from my former employer effect our eligibility for the ACA subsidy because they believe that I am transferring $ for purpose of establishing eligibility for ACA under the state program? If so, is that the end of getting premium subsidies? We can make the full premium payments but will be rather painful and would curtail future contributions to 401k accordingly. There is an appeal process but wondering if someone has prior experience with this and can advise whether I should bother with an appeal.
 
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I didn't go through your numbers but are you going to have reduced income in 2022? If so, you must explicitly state that in a letter to explain it. If there are documents which show that you no longer have or have reduced employment income you also need to submit those as well.
 
Since you are in MA, there may be some state thing that overrides the typical answer/experience. But, no, subsidies should still apply. It's entirely possible, however, that you'll get them on the back end if this is your first year on the ACA (by way of a tax deduction/refund). IOW, not eligible now, but you'll get them back for your 2022 full tax year filing in 23, once your income is final. Then, with a picture of "real" income behind you, it will work fine after that.

Yes it's worth an appeal, but did the denial come from the state or the fed? Some states have a different way of doing things.

But
 
Can you summarize the original post?

Your expected 2022 income is: $ (please fill in the blank)
 
Not sure what else I can provide to document reduced income other than recent paystubs showing YTD income. I think the State is looking at previous tax filings in 2020 and earlier showing much higher income so maybe go with the appeal process and see where they're coming from:confused:
 
What is your expected 2022 income?

You don't show past documentation for future reduced income, you state it clearly in the application process documents. ACA assumes you will earn a similar amount of income as you have in the past. You need to set them straight.
 
In your appeal you would state you are now retired, hence 2021 is moot, and make it very VERY simple. Focus only on your 2022 projections. Ignore 2021 unless specifically asked.

When I apply for coverage each year I'm asked for that coming year's income. Don't even get into agi vs gross and deductions, etc., if you appeal, talk in agi/net numbers only. If your application is as complicated as your post, that might be why there's an issue. Get very simple in your 2022 numbers in your appeal - even post a draft here before you call/write to anyone?
 
Thanks Aerides. To your earlier question - the denial was from the State. This is first year of ACA. Simplified version is my total income (AGI) for 2022 is expected to be $28.9K and DW's income expected to be 24.4K. That's it?
 
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I think you need to appeal and provide a line by line pro forma projection of your 2022 MAGI... use the Form 1040 lines and provide all the details. Don't confuse things with 2021 or 2020.

From what you wrote:

Self-employment income:.....$14.0k
DW part-time work:...............24.5k
Interest/dividends...................2.0k

Total...................................$40.5k

How are you getting $95.5k/$53.5k?... you neew to lay it all out for them... make it easy for them to approve you.

Also, does Massachusetts have ACA Navigators... people who help guide you through the application process? If so, get one to help you. I do have a faint recollection that Massachusetts is different.
 
The numbers you cited don't include the 55K from my on-call consulting with my former company. Deductions from 401k, HSA, LTC, etc. get AGI down to about 53.5K. Good call on the Navigators. I will see if I can get some assistance from them for the appeal process. Thanks!
 
Thanks Aerides. To your earlier question - the denial was from the State. This is first year of ACA. Simplified version is my total income (AGI) for 2022 is expected to be $28.9K and DW's income expected to be 24.4K. That's it?

ACA subsidies for 2022 are based on your estimated AGI for 2022 relative to FPL. (Technically it's a modified AGI, but I think that none of the modifications apply to you.)

So on your 2020 tax return, your AGI is on line 11. Dig out your 2020 tax return and learn how that number is calculated. Then figure out, based on any changes in your income picture, what the equivalent number will be on your 2022 tax return.

Then you just have to answer the questions from your state's exchange (or supply documentation in the way pb4uski outlined) so that they understand what your 2022 AGI is estimated to be.

It sounds to me like the information you provided to them is either inaccurate or confusing or both. I think working with a navigator or an exchange person to understand where the disconnect is and addressing it is what you need.

As an aside, you're talking about your and your wife's income separately. If you file with tax status of Married Filing Separately (which might be why you're talking about your income separately), then you are not eligible for ACA subsidies. If you supplied a 2020 tax return with a MFS filing status, that could be the problem. You might need to somehow indicate that you're going to file MFJ for 2022 to get the subsidies. See the flowchart here:

https://www.irs.gov/affordable-care...remium-tax-credit-flow-chart-are-you-eligible

(specifically the fifth blue box down the left).
 
As Aerides mentioned above - if you qualify for the premium tax credit but the state is not believing your income estimates, you'll get the premium tax credits after the fact when you file for you 2022 income tax in spring of 2023. Sure it's a pain to pay the full premium up front, but the PTC will come back to you based on your *actual* income.

Also MAGI (modified AGI) is what is used for your ACA PTCs. Some tax deductions are added back to your AGI for the MAGI.
 
As Aerides mentioned above - if you qualify for the premium tax credit but the state is not believing your income estimates, you'll get the premium tax credits after the fact when you file for you 2022 income tax in spring of 2023. Sure it's a pain to pay the full premium up front, but the PTC will come back to you based on your *actual* income.

My insurance lets me pay monthly with a credit card, so I get 2% cash back. So, there can be an upside to paying the full premium up front, if you can pay by CC.

I can't get anything close to 2% risk free (aside from Ibonds).
 
The numbers you cited don't include the 55K from my on-call consulting with my former company. Deductions from 401k, HSA, LTC, etc. get AGI down to about 53.5K. Good call on the Navigators. I will see if I can get some assistance from them for the appeal process. Thanks!

If you are confusing all of us here with your income dates and amounts, don't call them yet, get those numbers straight.

You need to be talking only in 2022 income - adjusted, after deductions. That $55k you mention again here, in the top of thread you said that was 2021? If so, ignore it.

Until/unless the person asks you, specifically, you don't need to go into 2021 numbers. "I retired this year, my income will be far less in 2022, now it will be ~$50k. How do I get the subsidy restored?" and go from there.

Good luck!
 
Yes, appeal, if only to get a clear answer, since all this stuff is so complex. I appealed our similar decline of 2022 subsidies recently in Minnesota. It was simple to do and I had a phone-hearing with an actual judge, not a bureaucrat.

We applied for subsidies in 2021 after the American Rescue Plan Act passed last spring, because DW received some unemployment income in early 2021. I was alert to that little nugget and decided we had nothing to lose by applying. I was pleasantly shocked that we were approved, and we received $1,200/month from August - December. Thank you ARPA.

The way I’d read the news accounts, if we qualified in 2021, we automatically qualified in 2022. What I learned in my hearing is that we automatically qualify to buy a bronze plan with an 8.5% income cap in 2022. The subsidy due to unemployment income was only for 2021. As always, American healthcare is far too confusing and expensive but at least I have a rule-based answer. Good luck.
 
Thanks all for your suggestions! I will appeal and just present our 2022 projections for AGI and see where that goes. Good to know that I should be able to get back the premium subsidy when filing in 2023 so will use the CC payment route if it comes to that and it is allowed. Will also call a local Navigator to make sure I have my numbers correct - we are MFJ so plan is to stick with just total AGI b/n the two of us projected for 2022. Will let you know how things turn out down the road. Happy Holidays everyone!
 
The way I’d read the news accounts, if we qualified in 2021, we automatically qualified in 2022.

This is not true as a general statement but probably happens to be true most of the time.

Anyone (pretty much - I guess you have to have an SSN) can buy an ACA plan. And the 400% FPL cliff has been eliminated for 2021 and 2022, so if a person qualified in 2021 *and will have similar income in 2022* then they also typically will qualify for 2022.

The unemployment thing was only for 2021, so a person who qualified based on that criteria in 2021 but would have otherwise not qualified, would likely not qualify in 2022.
 
I *just* qualified for ACA subsidy a week ago, this is my first time having that. Last year was *awesome*. I sold my business, therefore I was fired fair and square and I was an employee on the books with all taxes. *SO* not only did I get the Federal+State unemployment....but a HUGE ACA subsidy ! Anyway .....

Usually my taxable income was high...anywhere from $120k, to $700k in a few good years.

All I did was type a paragraph on Word.....about how I sold my business last year, and this year I'll have NO W-2 income. I said my *estimated* investment income was around $93,000.... and I broke it down in 2 bullet points: Rental Income and Stock dividends/gains.

I concluded it that I fully understand this is subject to audit, and I highly doubt I'll be higher than these numbers.

I sent it via my state's exchange. It didn't have a tab for "whiney letter" so I just used one of the other tabs - -- "unemployment benefits letter" because I had to pick something. Got a reply that they have my ticket. Then it's under review. Then it was accepted.

3 days later it confirmed a $786 subsidy.

My fear is....not that my income is higher next year....BUT what if it's lower? I hope they can't force me on Medicaid the following year.
 
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